10.6 Cardiac cephalalgia

Migraine-like headache, usually but not always aggravated by exercise, occurring during an episode of myocardial ischaemia. It is relieved by nitroglycerine.

Diagnostic criteria:
A. Any headache fulfilling criterion C
B. Acute myocardial ischaemia has been demonstrated
C. Evidence of causation demonstrated by at least two of the following:

    1. headache has developed in temporal relation to onset of acute myocardial ischaemia
    2. either or both of the following:

      a) headache has significantly worsened in parallel with worsening of the myocardial ischaemia
      b) headache has significantly improved or resolved in parallel with improvement in or resolution of the myocardial ischaemia

    3. headache has at least two of the following four characteristics:

      a) moderate to severe intensity
      b) accompanied by nausea
      c) not accompanied by phototophia or phonophobia
      d) aggravated by exertion

    4. headache is relieved by nitroglycerine or derivatives of it

D. Not better accounted for by another ICHD-3 diagnosis.

Diagnosis must include careful documentation of headache and simultaneous cardiac ischaemia during treadmill or nuclear cardiac stress testing. However, 10.6 Cardiac cephalalgia occurring at rest has been described.

Failure to recognise and correctly diagnose 10.6 Cardiac cephalalgia can have serious consequences. Therefore, distinguishing this disorder from 1.1 Migraine without aura is of crucial importance, particularly since vasoconstrictor medications (eg, triptans, ergots) are indicated in the treatment of migraine but contraindicated in patients with ischaemic heart disease. Both disorders can produce severe head pain accompanied by nausea, and both can be triggered by exertion. Migraine-like headache may be triggered by angina treatment such as nitroglycerine.